ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE …asecho.org/wordpress/wp-content/uploads/2014/09/Pediatric-AUC... · Task Force, American Academy of Pediatrics, American Heart Association,

Q1

J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . - , N O . - , 2 0 1 4

ª 2 0 1 4 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O UN DA T I O N I S S N 0 7 3 5 - 1 0 9 7 / $ 3 6 . 0 0

h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j a c c . 2 0 1 4 . 0 8 . 0 0 3P U B L I S H E D B Y E L S E V I E R I N C .

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354

55
APPROPRIATE USE CRITERIA 5657585960616263646566676869707172
ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE2014 Appropriate Use Criteria forInitial Transthoracic Echocardiographyin Outpatient Pediatric CardiologyA Report of the American College of Cardiology Appropriate Use Criteria Task Force,American Academy of Pediatrics, American Heart Association, American Society ofEchocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography andInterventions, Society of Cardiovascular Computed Tomography, Society for CardiovascularMagnetic Resonance, and Society of Pediatric Echocardiography

7374757677787980

Writing Group forEchocardiographyin OutpatientPediatricCardiology

Robert M. Campbell, MD, FACC, FAHA, FAAP,Chair

Pamela S. Douglas, MD, MACC, FAHA, FASEBenjamin W. Eidem, MD, FACC, FASE

FHRS,

This document was approved by the American College of Cardiology Boa

The American College of Cardiology requests that this document be cited

Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R. ACC

for initial transthoracic echocardiography in outpatient pediatric cardiology

Task Force, American Academy of Pediatrics, American Heart Association,

Cardiovascular Angiography and Interventions, Society of Cardiovascular Co

Society of Pediatric Echocardiography. J Am Coll Cardiol 2014;XX:xxx-xx.

This document is copublished in the Journal of the American Society of Ec

Copies: This document is available on the World Wide Web site of the Am

please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail

Permissions: Modification, alteration, enhancement, and/or distribution o

American College of Cardiology.

PGL 5.2.0 DTD � JAC20491_proof � 12 Septe

Wyman W. Lai, MD, MPH, FACC, FASELeo Lopez, MD, FACC, FAAP, FASERitu Sachdeva, MD, FACC, FAAP, FASE

818283
84 Rating Panel Robert M. Campbell, MD, FACC, FAHA, FAAP,
8586

FHRS,Chair*Pamela S. Douglas, MD, MACC, FAHA, FASE, Moderator*

87
Louis I. Bezold, MD, FACC, FAAP, FASEy 88
899091929394959697

William B. Blanchard, MD, FACC, FAHA, FAAP*Jeffrey R. Boris, MD, FACC*Bryan Cannon, MDzGregory J. Ensing, MD, FACC, FASExCraig E. Fleishman, MD, FACC, FASEjjMark A. Fogel, MD, FACC, FAHA, FAAP{B. Kelly Han, MD, FACC#Shabnam Jain, MD, MPH, FAAP*Mark B. Lewin, MDjj

Richard Lockwood, MD**G. Paul Matherne, MD, MBA, FACC, FAHAyyDavid Nykanen, MD, FACCzzCatherine L. Webb, MD, FACC, FAHA, FASEyyRobert Wiskind, MD, FAAP*

*American College of Cardiology representative. yAmerican Academy of

Pediatrics representative. zHeart Rhythm Society representative.

xAmerican Society of Echocardiography representative. jjSociety of

Pediatric Echocardiography representative. {Society for Cardiovascular

Magnetic Resonance representative. #Society of Cardiovascular Computed

Tomography representative. **Health Plan representative. yyAmerican

Heart Association representative. zzSociety for Cardiovascular

Angiography and Interventions representative.

rd of Trustees in June 2014.

as follows:

/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria

: a report of the American College of Cardiology Appropriate Use Criteria

American Society of Echocardiography, Heart Rhythm Society, Society for

mputed Tomography, Society for Cardiovascular Magnetic Resonance, and

hocardiography.

erican College of Cardiology (www.acc.org). For copies of this document,

[email protected].

f this document are not permitted without the express permission of the

mber 2014 � 3:25 pm � ce

9899

100101102103104105106107108

http://www.acc.org/

mailto:[email protected]

http://dx.doi.org/10.1016/j.jacc.2014.08.003

Campbell et al. J A C C V O L . - , N O . - , 2 0 1 4

AUC for Pediatric Echocardiography - , 2 0 1 4 :- –-

2

109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162

163164165

AppropriateUse CriteriaTask Force

Manesh R. Patel, MD, FACC, ChairChristopher M. Kramer, MD, FACC, FAHA,
Co-Chair
166
167168
Steven R. Bailey, MD, FACC, FAHA, FSCAIAlan S. Brown, MD, FACCJohn U. Doherty, MD, FACC, FAHA

PGL 5.2.0 DTD � JAC20491_proof � 12 Septemb

Pamela S. Douglas, MD, MACC, FAHA, FASERobert C. Hendel, MD, FACC, FAHA, FASNCBruce D. Lindsay, MD, FACCLeslee J. Shaw, PhD, FACC, FASNC, FAHAL. Samuel Wann, MD, MACCJoseph M. Allen, MA

169170171172

TABLE OF CONTENTS

173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

Figure 1. AUC Development Process . . . . . . . . . . . . . . . xx

3. GENERAL ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . XX

Figure 2. Factors Influencing Outcomesof an Imaging Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

4. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

5. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

6. RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

7. TRANSTHORACIC ECHOCARDIOGRAPHY IN

OUTPATIENT PEDIATRIC CARDIOLOGY:

APPROPRIATE USE CRITERIA (BY INDICATION) . . . . . XX

Table 1. Palpitations and Arrhythmias . . . . . . . . . . . . . xx

Table 2. Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

Table 3. Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

Table 4. Murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

Table 5. Other Symptoms and Signs . . . . . . . . . . . . . . . xx

Table 6. Prior Test Results . . . . . . . . . . . . . . . . . . . . . . . xx

Table 7. Systemic Disorders . . . . . . . . . . . . . . . . . . . . . . xx

Table 8. Family History of Cardiovascular Disease inPatients Without Signs or Symptoms and WithoutConfirmed Cardiac Diagnosis . . . . . . . . . . . . . . . . . . . . . xx

Table 9. Outpatient Neonates Without Post-NatalCardiology Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . xx

8. FLOW DIAGRAMS FOR COMMON

PATIENT SYMPTOMS . . . . . . . . . . . . . . . . . . . . . . . . . XX

Figure 3. Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

Figure 4. Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

Figure 5. Palpitaions and Arrhythmias . . . . . . . . . . . . . xx

Figure 6. Murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

9. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

Assumptions and Definitions . . . . . . . . . . . . . . . . . . . . xx

Indications and Ratings . . . . . . . . . . . . . . . . . . . . . . . . . xx

Comparison with the Adult Cardiology AUC . . . . . . . . xx

Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

Use of AUC to Improve Care . . . . . . . . . . . . . . . . . . . . . xx

10. CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XX

APPENDIX A

Appropriate Use Criteria for Initial TransthoracicEchocardiography in Outpatient Pediatric Cardiology:Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

APPENDIX B

Relationships With Industry (RWI) andOther Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

ABSTRACT

The American College of Cardiology (ACC) participated ina joint project with the American Society of Echocardi-ography, the Society of Pediatric Echocardiography, andseveral other subspecialty societies and organizations toestablish and evaluate Appropriate Use Criteria (AUC) forthe initial use of outpatient pediatric echocardiography.Assumptions for the AUC were identified, including thefact that all indications assumed a first-time transthoracicechocardiographic study in an outpatient setting for pa-tients without previously known heart disease. The defi-nitions for frequently used terminology in outpatientpediatric cardiology were established using publishedguidelines and standards and expert opinion. These AUCserve as a guide to help clinicians in the care of childrenwith possible heart disease, specifically in terms of whena transthoracic echocardiogram is warranted as an initialdiagnostic modality in the outpatient setting. They arealso a useful tool for education and provide the

er 2014 � 3:25 pm � ce

J A C C V O L . - , N O . - , 2 0 1 4 Campbell et al.- , 2 0 1 4 :- –- AUC for Pediatric Echocardiography

3

217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270

271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324

infrastructure for future quality improvement initiativesas well as research in healthcare delivery, outcomes, andresource utilization.

To complete the AUC process, the writing group iden-tified 113 indications based on common clinical scenariosand/or published clinical practice guidelines, and eachindication was classified into 1 of 9 categories of commonclinical presentations, including palpitations, syncope,chest pain, and murmur. A separate, independent ratingpanel evaluated each indication using a scoring scale of 1to 9, thereby designating each indication as “Appropriate”(median score 7 to 9), “May Be Appropriate” (medianscore 4 to 6), or “Rarely Appropriate” (median score 1 to3). Fifty-three indications were identified as Appropriate,28 as May Be Appropriate, and 32 as Rarely Appropriate.

PREFACE

In an effort to respond to the need for the rational use ofservices in the delivery of high quality care, the ACC hasundertaken a process to determine the appropriate use ofcardiovascular imaging and procedures for selected pa-tient indications.

AUC publications reflect an ongoing effort by the ACCto critically and systematically create, review, and cate-gorize clinical situations where diagnostic tests and pro-cedures are utilized by physicians caring for patients withknown or suspected cardiovascular diseases. The processis based on current understanding of the technical capa-bilities of the imaging modalities and procedures exam-ined. Although not intended to be entirely comprehensivedue to the wide diversity of clinical disease, the in-dications are meant to identify common scenariosencountered by the majority of contemporary practices.Given the breadth of information they convey, the in-dications do not directly correspond to the InternationalClassification of Diseases (ICD) system.

The ACC believes that careful blending of a broad rangeof clinical experiences and available evidence-based infor-mation will help guide a more efficient and equitable allo-cation of health care resources in cardiovascular imaging.The ultimate objective of AUC is to improve patient careand health outcomes in a cost-effective manner, but theyare not intended to ignore ambiguity and nuance intrinsicto clinical decision-making. Local parameters, such as theavailability or quality of equipment or personnel, may in-fluence the selection of certain tests or procedures. AUCthus should not be considered substitutes for sound clinicaljudgment and practice experience.

1. INTRODUCTION

Improvements in cardiovascular imaging technologiesand their application, particularly with increasing thera-peutic options for cardiovascular disease, have led to an

PGL 5.2.0 DTD � JAC20491_pro

increase in the utilization of such technologies. As theseimaging technologies and clinical applications continue toadvance, the healthcare community needs to understandhow best to incorporate these options into daily clinicalcare and how to choose between new and long-standing,established imaging technologies. In an effort to res-pond to this need and to ensure the effective use ofadvanced diagnostic imaging tools and procedures, theAUC project was initiated. The AUC in this document havebeen developed in order to promote effective patientcare, better clinical outcomes, and improved resourceutilization. This set of AUC should be useful not only forpediatric cardiologists, but also for general pediatriciansand family practitioners, who are frequently the first cli-nicians to consider the need for this modality.

Although AUC have been established for echocardiog-raphy in adult patients (1–3), a similar document for pe-diatric patients has not yet been published. This is partlybecause the scope of such a document would require animpossibly extensive list, if criteria were developed foreach congenital cardiac malformation and its variantsbefore and after intervention. Guidelines and standardsfor performing a pediatric echocardiogram, as well asrecommendations for quantification methods, havealready been published (4,5). However, the questionsoften raised by AUC of “when to do” and “how often todo” a pediatric echocardiogram still remained.

To address these concerns, the American College ofCardiology initiated an AUC document on pediatricechocardiography in the outpatient setting, since outpa-tient care is an important component of clinical pediatriccardiology. Children with heart disease represent a widelyvaried group of patients, frequently characterized bycomplex anatomic malformations requiring lifelongfollow-up. While echocardiography is the primary diag-nostic modality for children with established congenitaland acquired heart disease, the scope of the currentdocument has been limited to first-time outpatienttransthoracic echocardiographic studies in patientswithout previously known cardiac abnormalities. Thisnarrower set of clinical presentations has been chosenbecause of the high volume of such testing within pedi-atric cardiology. In addition, this initiative has establishedthe infrastructure to develop additional AUC for pediatricand congenital echocardiography in other settings.

2. METHODS

This document covers a wide array of potential signsand symptoms associated with cardiovascular disease inpediatric patients. A standardized approach was used tocreate different categories of indications with the goal ofcapturing actual clinical scenarios, without making the listof indications excessively long. Indications were created

of � 12 September 2014 � 3:25 pm � ce

1Negative consequences include the risks of the procedure (i.e., radiation or

contrast exposure) and the downstream impact of poor test performance such as

delay in diagnosis (false negatives) or inappropriate diagnosis (false positives).



4

325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365366367368369370371372373374375376377378

379380381382383384385386387388389390391392393394395396397398399400401402403404405406407408409410411412413414415416417418419420421422423424425426427428429430431432

to represent most of the possible uses of echocardiographyin the outpatient pediatric setting rather than limiting theAUC to indications for which evidence was available.

To identify and categorize the indications, a writinggroup of pediatric echocardiography experts was formedof representatives from a variety of organizations andsocieties. Wherever possible during the writing process,the group members would map the indications to rele-vant clinical guidelines and key publications or refer-ences (See Online Appendix). Once the indications wereformed, they were reviewed and critiqued by the parentAUC Task Force and numerous external reviewers repre-senting all pediatric cardiovascular specialties and pri-mary care. After the writing group incorporated thisinitial feedback, the indications were sent to an inde-pendent rating panel comprised of additional experts inthe pediatrics and pediatric cardiology realm, before be-ing sent back to the writing group for additional vetting.Each indication was then rated and classified as either“Appropriate care”, “May Be Appropriate care”, or“Rarely Appropriate care” based on these multiple roundsof review and revision (see Figure 1).

A detailed description of themethods used for rating theselected clinical indications is found in a previous publi-cation, “ACCF Proposed Method for Evaluating theAppropriateness of Cardiovascular Imaging,” (6) as well asthe updated version, “Appropriate Use of CardiovascularTechnology: 2013 ACCF Appropriate Use CriteriaMethodology Update: A Report of the American Collegeof Cardiology Foundation Appropriate Use Criteria TaskForce” (7). Briefly, this process combines evidence-basedmedicine and practice experience and engages a ratingpanel in a modified Delphi exercise. Other steps areconvening a formal writing group with diverse expertisein pediatric imaging and clinical care, circulating theindications for external review prior to being sent to therating panel, ensuring an appropriate balance ofexpertise and practice areas among the rating panelists,developing a standardized rating package that includesrelevant evidence, and establishing formal roles forfacilitating panel interaction at the face-to-face meeting.

The rating panel first evaluated the indications inde-pendently. Then, the panel was convened for a face-to-facemeeting for discussion of each indication. At this meeting,panel members were given their scores and a blindedsummary of their peers’ scores. After the meeting, panelmembers were then asked to independently provide theirfinal scores for each indication (See Online Appendix).

Although panel members were not provided explicitcost information to help determine their appropriate useratings, they were asked to implicitly consider cost as anadditional factor in their evaluation of appropriate use. Inrating these criteria, the AUC Rating Panel was asked toassess whether the use of the test for each indication

PGL 5.2.0 DTD � JAC20491_proof � 12

should be categorized as Appropriate care, May BeAppropriate care, or Rarely Appropriate care, and wasprovided the following definition of appropriate use:

An appropriate imaging study is one in which the ex-

pected incremental information, combined with clinical

judgment, exceeds the expected negative consequences1

by a sufficiently wide margin for a specific indication

that the procedure is generally considered acceptable

care and a reasonable approach for the indication.

The rating panel scored each indication as follows:Median Score 7 to 9: Appropriate test for specific indi-

cation (test is generally acceptable and is a reasonableapproach for the indication).

An appropriate option for management of patients in thispopulation due to benefits generally outweighing risks;effective option for individual care plans although notalways necessary depending on physician judgment andpatient specific preferences (i.e., procedure is generallyacceptable and is generally reasonable for the indication).

Median Score 4 to 6: May Be Appropriate test for specificindication (test may be generally acceptable and may be areasonable approach for the indication). May Be Appro-priate also implies that more research and/or patient in-formation is needed to classify the indication definitively.

At times an appropriate option for management of pa-tients in this population due to variable evidence or lack ofagreement regarding the benefits risks ratio, potentialbenefit based on practice experience in the absence of evi-dence, and/or variability in the population; effectivenessfor individual care must be determined by a patient’sphysician in consultation with the patient based on addi-tional clinical variables and judgment along with patientpreferences (i.e., procedure may be acceptable and may bereasonable for the indication).

Median Score 1 to 3: Rarely Appropriate test for specificindication (test is not generally acceptable and is not areasonable approach for the indication).

Rarely an appropriate option for management ofpatients in this population due to the lack of a clear benefit/risk advantage; rarely an effective option for individualcare plans; exceptions should have documentation of theclinical reasons for proceeding with this care option(i.e., procedure is not generally acceptable and is notgenerally reasonable for the indication).

The division of the numerical scores into 3 levels ofappropriateness is somewhat arbitrary and the numericdesignations should be viewed as existing on a contin-uum. Further, there may be diversity in clinical opinionfor particular clinical scenarios, such that scores in the

September 2014 � 3:25 pm � ce

http://jaccjacc.cardiosource.com/acc_documents/Peds_Echo_Online_Appx_Guideline_Mapping_&_References.pdf

http://jaccjacc.cardiosource.com/acc_documents/Peds_Echo_Online_Appx_Deidentified_Final_Scores.pdf

Develop list of indica ons, assump ons, and defini ons

Literature review and Guideline Mapping

Review Panel >30 members provide feedback

Wri ng Group revises indica ons

Ra ng Panel rates the Indica ons in two rounds

1st round – No Interac on

2nd Round – Panel Interac on

Appropriate Use Score

(7-9) Appropriate

(4-6) May Be Appropriate

(1-3) Rarely AppropriateProspec ve comparison

with clinical records

% Use that is Appropriate, May Be Appropriate, or

Rarely Appropriate

Prospec ve clinical decision aids

Increase Appropriate Use

Indi

caon

Dev

elop

men

tAp

prop

riate

ness

De

term

ina

onVa

lida

on

FIGURE 1 AUC Development Process


5

433434435436437438439440441442443444445446447448449450451452453454455456457458459460461462463464465466467468469470471472473474475476477478479480481482483484485486

487488489490491492493494495496497498499500501502503504505506507508509510511512513514515516517518519520521522523524525526527528529530531532533534535536537538539540

intermediate level of appropriate use should be labeled“May Be Appropriate,” as critical patient or research datamay be lacking or discordant. This designation should bea prompt to the field to carry out definitive researchinvestigation whenever possible. It is anticipated that theAUC reports will continue to be revised as further data aregenerated and information from criteria implementationis accumulated.

To prevent bias in the scoring process, the rating panel,by design, included a minority of specialists in pediatricechocardiography. Specialists, while offering importantclinical and technical insights, might have a natural ten-dency to rate the indications within their specialty as moreappropriate than non-specialists. In addition, care wastaken to provide objective, nonbiased information, in-cluding guidelines and key references, to the rating panel.

The level of agreement among panelists was analyzedbased on the RAND Corporation’s BIOMED ConcertedAction on Appropriateness rule (8) for a panel of 14 to16 members. As such, agreement was defined as anindication where 4 or fewer panelists’ ratings fell outsidethe 3-point region containing the median score.

Disagreement was defined as occurring when at least 5panelists’ ratings fell in both the Appropriate and theRarely Appropriate categories. Any indication havingdisagreement was categorized as May Be Appropriateregardless of the final median score.


3. GENERAL ASSUMPTIONS

1. This document will address the initial use of outpa-tient transthoracic echocardiography (TTE) duringpediatric (# 18 years of age) outpatient care. AlthoughTTE is also an essential tool in hospitalized patients,discussion of indications for this use is beyond thescope of this document.

2. This AUC document will not address the use of TTE inpatients with previously known structural, functional,or primary electrical cardiac abnormalities.

3. A comprehensive TTE examination may include 2-dimensional, M-mode, and 3-dimensional imaging aswell as spectral and color Doppler evaluation, all ofwhich are important elements (9–11) to evaluate rele-vant cardiac structures and hemodynamics. Acomprehensive TTE report includes interpretation ofall aspects of the TTE.

4. The use of transesophageal or stress echocardiogra-phy will not be addressed in this document.

5. This document assumes that any other more defini-tive diagnostic test, including but not limited toelectrocardiogram (ECG), chest X-ray, or genetictesting, when appropriate will be considered prior toordering a TTE.

6. All standard TTE techniques for image acquisition areavailable for each indication and have a sensitivity


Patient PatientSelection

ImageAcquisition

ImageInterpretation

Imaging Process

Laboratory Structure

ResultsCommunication

ImprovedPatient Care(Outcomes)

FIGURE 2 Factors Influencing Outcomes of an Imaging Study (16)



6

541542543544545546547548549550551552553554555556557558559560561562563564565566567568569570571572573574575576577578579580581582583584585586587588589590591592593594

595596597598599600601602603604605606607608609610611612613614615616617618619620621622623624625626627628629630631632633634635636637638639640641642643644645646647648

and specificity similar to those found in the publishedliterature.

7. The test is performed and interpreted by qualifiedindividual(s) in a facility that is in compliance withnational standards for performing pediatric echocar-diograms (4).

8. AUC is one aspect of quality for imaging proceduresoccurring at the time of patient selection. Severaladditional factors should be addressed to supporthigh-quality results (see Figure 2). These other factorsare important but are not covered in this document.

9. The range of potential indications for echocardiogra-phy is quite large, particularly in comparison withother cardiovascular imaging tests. Thus, the in-dications are, at times, purposefully broad to cover anarray of cardiovascular signs and symptoms and toaccount for the ordering physician’s best judgment asto the presence of cardiovascular abnormalities.Additionally, there are likely clinical scenarios thatare not covered in this document.

10. A qualified clinician has obtained a complete clinicalhistory and performed the physical examination suchthat the clinical status of the patient can be assumedto be valid as stated in the indication (e.g., anasymptomatic patient is truly asymptomatic for thecondition in question and sufficient questioning ofthe patient has been undertaken).

11. Some indications address whether or not an ECGhas been obtained and whether or not it revealsany abnormalities as influencing the appropriatenessof additional echocardiographic assessment. It isbeyond the scope of this document to define everypossible clinical scenario involving specific ECGabnormalities. Therefore, the term “abnormal ECG”refers to only clinically pertinent ECG findings.Criteria for “abnormal ECG” will be based upon stan-dard published ECG normal values in pediatric pa-tients (12–15).


12. If the reason for a test can be assigned to more thanone indication, it is classified under the most clinicallysignificant indication.

13. The term family history in this document refers tofirst-degree relatives only.

14. Cost is considered implicitly in the appropriate usedetermination. Clinical benefits should always beconsidered first, and costs should be considered inrelationship to these benefits in order to better conveynet value. For example, a procedure with moderateclinical efficacy for a given AUC indication should notbe scored as more appropriate than a procedure withhigh clinical efficacy solely due to its lower cost. Whenscientific evidence exists to support clinical benefit,cost efficiency and cost effectiveness should beconsidered for any indication.

15. For each indication, the rating reflects whetherthe echocardiogram is reasonable for the patient ac-cording to the appropriate use definition, not whetherthe test is preferred over another modality. It is notassumed that the decision to perform a diagnostic testhas already been made. The level of appropriatenessalso does not consider issues of local availability orskill for any modality.

16. The category of May Be Appropriate is used wheninsufficient data are available for a definitive catego-rization or when there is substantial disagreementregarding the appropriateness of that indication. Thedesignation May Be Appropriate should not be used asgrounds for denial of reimbursement.

17. This manuscript does not address whether a cardiol-ogy consultation is required prior to the echocardio-gram unless specified in the indication.

4. DEFINITIONS

Abnormal electrocardiogram (ECG): Electrocardiographicfindings regarded as probably or definitely abnormal



7

649650651652653654655656657658659660661662663664665666667668669670671672673674675676677678679680681682683684685686687688689690691692693694695696697698699700701702

703704705706707708709710711712713714715716717718719720721722723724725726727728729730731732733734735736737738739740741742743744745746747748749750751

according to age as well as clinically significant, andincluding but not limited to ventricular hypertrophy,atrial enlargement, complete bundle branch block, atrio-ventricular block, prolonged QTc, abnormal T waves orST-T wave segments, Wolff-Parkinson-White syndrome,premature atrial contractions (PACs), premature ventric-ular contractions (PVCs), supraventricular tachycardia,ventricular tachycardia, and Brugada syndrome

Arrhythmia: Documented irregular and/or abnormalheart rate or rhythm (Patients with palpitations do notnecessarily have an arrhythmia, and patients with anarrhythmia do not necessarily experience palpitations)

Cardiomyopathy: Disease affecting the structure and/orfunction of the myocardium, including but not limited tohypertrophic, dilated, or restrictive cardiomyopathy, leftventricular non-compaction, or arrhythmogenic rightventricular cardiomyopathy

Channelopathy: A clinical syndrome involving a geneticmutation or acquired malfunction of the proteins formingthe myocardial ion channels (including but not limited toNaþ, Kþ, and Ca2þ) of the cardiovascular electrical sys-tem, including but not limited to long QT syndrome, shortQT syndrome, catecholaminergic polymorphic ventriculartachycardia, and Brugada syndrome

Chest pain: Physical discomfort in the anterior thoracicregion

Congestive heart failure: A condition in which the heartis unable to pump enough blood to meet the body’smetabolic demands

Cyanosis: Bluish discoloration of the skin and mucousmembranes

Desaturation: For pediatric patients other than new-borns, an oxygen saturation <95% as measured by pulseoximeter; for newborns $24 hours of age, an oxygensaturation that is (a) <90% in the initial screen or in repeatscreens, (b) <95% in the right hand and foot on 3 mea-sures, each separated by 1 hour, or (c) a >3% absolutedifference in oxygen saturation between the right handand foot on 3 measures, each separated by 1 hour (17)

Echogenic focus: Small bright spot(s) frequently seen ona fetal echocardiogram, usually related to the ventricularpapillary muscles and chordae and generally considered abenign finding

Hypertension: Average systolic and/or diastolic bloodpressure that is $95th percentile for gender, age, andheight on 3 or more occasions

Murmur: Additional heart or vascular sound due tonormal or abnormal turbulent blood flow heard duringauscultation

752753754755

Innocent murmur: Murmur that is consistent withnormal blood flow and is determined not to berelated to any structural abnormalities of the heart orgreat vessels, including but not limited to Still’s


murmur, pulmonary flow murmur, physiologic pe-ripheral pulmonary stenosis, supraclavicular arterialbruit, and venous hum; most innocent murmurs aresoft (less than or equal to grade 2/6), heard in earlysystole, characterized as crescendo-decrescendotype, and may vary with position

Pathologic murmur: Murmur that is suggestive of thepresence of a cardiovascular abnormality (not clearlyinnocent sounding), including but not limited todiastolic murmurs, holosystolic murmurs, late sys-tolic murmurs, grade 3/6 systolic murmur or louder,continuousmurmurs other than venous hums, harshmurmurs, and murmurs that are provoked or be-come louder with changes in position (from squat-ting to standing) or during the strain phase of aValsalva maneuver

Neonate: A child that is less than or equal to 28 days oldNeurocardiogenic syncope: A type of syncope typically

occurring in the upright position, in which the triggeringof a neural reflex results in a usually self-limited episodeof systemic hypotension and/or bradycardia or asystole

Palpitations: An unpleasant sensation of rapid, irreg-ular, and/or forceful beating of the heart

Pre-Syncope: A state of experiencing lightheadedness,dizziness, weakness, visual changes (such as spots, tunnelvision, or loss of vision), auditory changes (ringing,buzzing, or muffled hearing), or feeling hot or coldwithout loss of consciousness

Syncope: Sudden temporary loss of consciousness asso-ciated with a loss of postural tone and with spontaneousrecovery that does not require electrical or chemicalcardioversion

5. ABBREVIATIONS

AUC ¼ Appropriate Use CriteriaECG ¼ electrocardiogramPAC ¼ premature atrial contractionPVC ¼ premature ventricular contractionTTE ¼ transthoracic echocardiogram

6. RESULTS

The final ratings for pediatric echocardiography are listedby indication in Tables 1 to 9. The final score for eachindication reflects the median score of the 15 RatingPanel members and has been labeled according to thecategories of Appropriate (median 7 to 9), May BeAppropriate (median 4 to 6), or Rarely Appropriate (me-dian 1 to 3). In the tables, the final score for each indi-cation is shown in parentheses with the ratings. Out of113 total indications, 53 were considered Appropriate

2 September 2014 � 3:25 pm � ce

756



8

757758759760761762763764765766767768769770771772773774775776777778779780781782783784785786787788789790791792793794795796797798799800801802803804805806807808809810

811812813814815816817818819

(47%), 28 were considered May Be Appropriate (25%),and 32 were considered Rarely Appropriate (28%). To seethe indications listed by Appropriate Use rating, see theOnline Appendix. The Discussion section highlightsfurther trends in scoring.

Figures 3, 4, 5, and 6 illustrate flow diagrams based oncommon patient symptoms (chest pain, syncope, palpi-tations and arrhythmias, and murmur) that the cliniciancan use to narrow down patient information until the

TABLE 1 Palpitations and Arrhythmias

Indication

Palpitati

1. Palpitations with no other symptoms or signs of cardiovascular dise

2. Palpitations with no other symptoms or signs of cardiovascular dise

3. Palpitations with abnormal ECG

4. Palpitations with family history of a channelopathy

5. Palpitations in a patient with known channelopathy

6. Palpitations with family history at a young age (before the age of 5and/or pacemaker or implantable defibrillator placement

7. Palpitations with family history of cardiomyopathy

8. Palpitations in a patient with known cardiomyopathy

ECG Find

9. PACs in the prenatal or neonatal period

10. PACs after the neonatal period

11. Supraventricular tachycardia

12. PVCs in the prenatal or neonatal period

13. PVCs after the neonatal period

14. Ventricular tachycardia

15. Sinus bradycardia

16. Sinus arrhythmia

The number in parentheses next to the rating reflects the median score for that indication

Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECGtricular contractions.

TABLE 2 Syncope

Indication

17. Syncope with or without palpitations and with no recent ECG

18. Syncope with no other symptoms or signs of cardiovascular diseas

19. Syncope with abnormal ECG

20. Syncope with family history of channelopathy

21. Syncope with family history at a young age (before the age of 50pacemaker or implantable defibrillator placement

22. Syncope with family history of cardiomyopathy

23. Probable neurocardiogenic (vasovagal) syncope

24. Unexplained pre-syncope

25. Exertional syncope

26. Unexplained post-exertional syncope

27. Syncope or pre-syncope with a known non-cardiovascular cause

The number in parenthesis next to the rating reflects the median score for that indication

Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG


820

AUC score is attained. Likewise, Figure 7 (a-d) in theOnline Appendix shows flow diagrams grouped by clin-ical presentation, such as family history and testfindings.

7. TRANSTHORACIC ECHOCARDIOGRAPHY IN

OUTPATIENT PEDIATRIC CARDIOLOGY:

APPROPRIATE USE CRITERIA (BY INDICATION)

Appropriate Use Rating

ons

ase, a benign family history, and no recent ECG R (2)

ase, a benign family history, and a normal ECG R (1)

M (6)

R (3)

M (4)

0 years) of sudden cardiac arrest or death A (7)

A (9)

A (9)

ings

R (3)

R (3)

A (7)

M (6)

M (6)

A (9)

R (2)

R (1)

.

¼ electrocardiogram; PACs ¼ premature atrial contractions; PVCs ¼ premature ven-

Appropriate Use Rating

R (3)

e, a benign family history, and a normal ECG R (2)

A (7)

M (5)

years) of sudden cardiac arrest or death and/or A (9)

A (9)

R (2)

M (4)

A (9)

A (7)

R (2)

.

¼ Electrocardiogram.


821822823824825826827828829830831832833834835836837838839840841842843844845846847848849850851852853854855856857858859860861862863864

http://jaccjacc.cardiosource.com/acc_documents/Peds_Echo_Online_Appx_Indications_by_Appropriate_Use_Rating.pdf

http://jaccjacc.cardiosource.com/acc_documents/Peds_Echo_Online_Appx_Flow_Diagrams_by_clinical_presentation.pdf

TABLE 4 Murmur

Indication Appropriate Use Rating

39. Presumptively innocent murmur with no symptoms, signs, or findings of cardiovascular disease and a benignfamily history

R (1)

40. Presumptively innocent murmur with signs, symptoms, or findings of cardiovascular disease A (7)

41. Pathologic murmur A (9)

The number in parenthesis next to the rating reflects the median score for that indication.

Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.

TABLE 5 Other Symptoms and Signs


42. Symptoms and/or signs suggestive of congestive heart failure, including but not limited to respiratory distress,poor peripheral pulses, feeding difficulty, decreased urine output, edema, and/or hepatomegaly

A (9)

43. Chest wall deformities and scoliosis pre-operatively M (6)

44. Fatigue with no other signs and symptoms of cardiovascular disease, a normal ECG, and a benign family history R (3)

45. Signs and symptoms of endocarditis in the absence of blood culture data or a negative blood culture A (8)

46. Unexplained fever without other evidence for cardiovascular or systemic involvement M (5)

47. Central cyanosis A (8)

48. Isolated acrocyanosis R (1)



TABLE 3 Chest Pain


28. Chest pain with no other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG R (2)

29. Chest pain with other symptoms or signs of cardiovascular disease, a benign family history, and a normal ECG M (6)

30. Exertional chest pain A (8)

31. Non-exertional chest pain with no recent ECG R (3)

32. Non-exertional chest pain with normal ECG R (1)

33. Non-exertional chest pain with abnormal ECG A (7)

34. Chest pain with family history of sudden unexplained death or cardiomyopathy A (8)

35. Chest pain with family history of premature coronary artery disease M (4)

36. Chest pain with recent onset of fever M (6)

37. Reproducible chest pain with palpation or deep inspiration R (1)

38. Chest pain with recent illicit drug use M (6)




9

PGL 5.2.0 DTD � JAC20491_proof � 12 September 2014 � 3:25 pm � ce

865866867868869870871872873874875876877878879880881882883884885886887888889890891892893894895896897898899900901902903904905906907908909910911912913914915916917918

919920921922923924925926927928929930931932933934935936937938939940941942943944945946947948949950951952953954955956957958959960961962963964965966967968969970971972

TABLE 7 Systemic Disorders


62. Cancer without chemotherapy M (5)

63. Prior to or during chemotherapy in cancer A (8)

64. Sickle cell disease and other hemoglobinopathies A (8)

65. Connective tissue disorder such as Marfan, Loeys Dietz, and other aortopathy syndromes A (9)

66. Suspected connective tissue disorder A (7)

67. Clinically suspected syndrome or extracardiac congenital anomaly known to be associated with congenital heart disease A (9)

68. Human immunodeficiency virus infection A (8)

69. Suspected or confirmed Kawasaki disease A (9)

70. Suspected or confirmed Takayasu arteritis A (9)

71. Suspected or confirmed acute rheumatic fever A (9)

72. Systemic lupus erythematosis and autoimmune disorders A (7)

73. Muscular dystrophy A (9)

74. Systemic hypertension A (9)

75. Renal failure A (7)

76. Obesity without other cardiovascular risk factors R (2)

77. Obesity with obstructive sleep apnea M (6)

78. Obesity with other cardiovascular risk factors M (6)

79. Diabetes mellitus R (3)

80. Lipid disorders R (3)

81. Stroke A (8)

82. Seizures, other neurologic disorders, or psychiatric disorders R (2)

83. Suspected pulmonary hypertension A (9)

84. Gastrointestinal disorders, not otherwise specified R (2)

85. Hepatic disorders M (4)

86. Failure to thrive M (5)

87. Storage diseases, mitochondrial and metabolic disorders A (8)

88. Abnormalities of visceral or cardiac situs A (9)


Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate.

TABLE 6 Prior Test Results


49. Known channelopathy M (4)

50. Genotype positive for cardiomyopathy A (9)

51. Abnormal chest X-ray findings suggestive of cardiovascular disease A (9)

52. Abnormal ECG without symptoms A (7)

53. Desaturation based on pulse oximetry A (9)

54. Previously normal echocardiogram with no change in cardiovascular status or family history R (1)

55. Previously normal echocardiogram with a change in cardiovascular status and/or a new family history suggestive ofheritable heart disease

A (7)

56. Elevated anti-streptolysin O titers without suspicion for rheumatic fever R (3)

57. Chromosomal abnormality known to be associated with cardiovascular disease A (9)

58. Chromosomal abnormality with undefined risk for cardiovascular disease M (5)

59. Positive blood cultures suggestive of infective endocarditis A (9)

60. Abnormal cardiac biomarkers A (9)

61. Abnormal barium swallow or bronchoscopy suggesting vascular ring A (7)





10


973974975976977978979980981982983984985986987988989990991992993994995996997998999100010011002100310041005100610071008100910101011101210131014101510161017101810191020102110221023102410251026

102710281029103010311032103310341035103610371038103910401041104210431044104510461047104810491050105110521053105410551056105710581059106010611062106310641065106610671068106910701071107210731074107510761077107810791080

TABLE 8Family History of Cardiovascular Disease in Patients Without Signs or Symptoms and Without ConfirmedCardiac Diagnosis


89. Unexplained sudden death before the age of 50 years M (6)

90. Premature coronary artery disease before the age of 50 years R (2)

91. Channelopathy R (3)

92. Hypertrophic cardiomyopathy A (9)

93. Non-ischemic dilated cardiomyopathy A (9)

94. Other cardiomyopathies A (8)

95. Unspecified cardiovascular disease R (3)

96. Disease at high risk for cardiovascular involvement, including but not limited to diabetes, systemic hypertension,obesity, stroke, and peripheral vascular disease

R (2)

97. Genetic disorder at high risk for cardiovascular involvement A (7)

98. Marfan or Loeys Dietz syndrome A (7)

99. Connective tissue disorder other than Marfan or Loeys Dietz syndrome M (6)

100. Congenital left-sided heart lesion, including but not limited to mitral stenosis, left ventricular outflow tractobstruction, bicuspid aortic valve, aortic coarctation, and/or hypoplastic left heart syndrome

M (6)

101. Congenital heart disease other than the congenital left-sided heart lesions M (5)

102. Idiopathic pulmonary arterial hypertension M (5)

103. Heritable pulmonary arterial hypertension A (8)

104. Pulmonary arterial hypertension other than idiopathic and heritable R (3)

105. Consanguinity R (3)



TABLE 9 Outpatient Neonates Without Post-Natal Cardiology Evaluation


106. Suspected cardiovascular abnormality on fetal echocardiogram A (9)

107. Isolated echogenic focus on fetal ultrasound R (2)

108. Maternal infection during pregnancy or delivery with potential fetal/neonatal cardiac sequelae A (7)

109. Maternal diabetes with no prior fetal echocardiogram M (6)

110. Maternal diabetes with a normal fetal echocardiogram M (4)

111. Maternal phenylketonuria A (7)

112. Maternal autoimmune disorder M (5)

113. Maternal teratogen exposure M (6)




11


108110821083108410851086108710881089109010911092109310941095109610971098109911001101110211031104110511061107110811091110111111121113111411151116111711181119112011211122112311241125112611271128112911301131113211331134

113511361137113811391140114111421143114411451146114711481149115011511152115311541155115611571158115911601161116211631164116511661167116811691170117111721173117411751176117711781179118011811182118311841185118611871188

print&web4C=F

PO

print&web4C=FPO



12

118911901191119211931194119511961197119811991200120112021203120412051206120712081209121012111212121312141215121612171218121912201221122212231224122512261227122812291230123112321233123412351236123712381239124012411242

1243124412451246

8. FLOW DIAGRAMS FOR COMMON

PATIENT SYMPTOMS

FIGURE 3 Chest Pain

Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication. *See

Discussion section. Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram.

FIGURE 4 Syncope

Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.

Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram; ICD ¼ Implantable Cardioverter Defibrillator.


12471248124912501251125212531254125512561257125812591260126112621263126412651266126712681269127012711272127312741275127612771278127912801281128212831284128512861287128812891290129112921293129412951296

print&web4C=FPO

FIGURE 5 Palpitations and Arrhythmias

Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication. *See

Discussion section. Abbreviations: A ¼ Appropriate; M ¼ May Be Appropriate; R ¼ Rarely Appropriate; ECG ¼ Electrocardiogram; ICD ¼ Implantable Car-

dioverter Defibrillator; PACs ¼ Premature Atrial Contractions; PVCs ¼ Premature Ventricular Contractions.

print&web4C=FPO

FIGURE 6 Murmur

Each indication is preceded with a number sign. The rating of A, M, or R is then followed by the median score in parenthesis for that particular indication.



13


129712981299130013011302130313041305130613071308130913101311131213131314131513161317131813191320132113221323132413251326132713281329133013311332133313341335133613371338133913401341134213431344134513461347134813491350

135113521353135413551356135713581359136013611362136313641365136613671368136913701371137213731374137513761377137813791380138113821383138413851386138713881389139013911392139313941395139613971398139914001401140214031404



14

140514061407140814091410141114121413141414151416141714181419142014211422142314241425142614271428142914301431143214331434143514361437143814391440144114421443144414451446144714481449145014511452145314541455145614571458

145914601461146214631464146514661467146814691470147114721473147414751476147714781479148014811482148314841485148614871488148914901491149214931494149514961497149814991500150115021503150415051506150715081509151015111512

9. DISCUSSION

This is the first report by the American College of Cardi-ology addressing appropriate use in the field of pediatriccardiology. Although the use of AUC for various areas ofcardiovascular imaging in adult cardiology has beenestablished since 2005, there has not been a tool toguide practice in pediatric cardiology (1,18). Given thehigh level of utilization of echocardiography in theoutpatient setting, this topic was chosen as the subjectfor the first pediatric AUC, and was intentionallyrestricted to initial, outpatient, and transthoracic echo-cardiographic evaluation. Of the various diagnostic mo-dalities, echocardiography remains the most readilyavailable, non-invasive and highly diagnostic tool forassessing cardiac structure, function and hemodynamicsin those with suspected cardiac disease. This report willhelp us establish the infrastructure precedent forexpanding AUC for echocardiography in pediatric pa-tients as well as AUC for other diagnostic modalities andprocedures used in this field.

It is important to note the differences between clinicalpractice guidelines and AUC (19). The American College ofCardiology guidelines have been developed by leaders inthe field of cardiovascular medicine using evidence-based documents and expert opinion and are in generalquite broad. Even though AUC are evidence based,they are created around possible clinical scenariosthat are encountered in everyday practice rather thanstarting with options based on current evidence.Echocardiography is the most common imaging modalityused in cardiology, but there is evidence that it may notbe a cost-effective or high-yield diagnostic test for someindications included in this document (20–29). The AUCaddress a reasonable role of echocardiography. Eachindividual patient is unique and the possible use ofechocardiography deserves to be considered in fullclinical context. It is noteworthy that there are no recentpractice guidelines for indications of echocardiographyin pediatric patients and this report may become aclinically useful guide for practitioners (30).

Assumptions and Definitions

Some of the assumptions used while writing this reportare important to emphasize. It is assumed that a thor-ough history and physical examination has been per-formed by a qualified clinician and that use of othermore diagnostic tests has been considered prior toordering an echocardiogram. It is also assumed that theechocardiogram is performed and interpreted by quali-fied individuals. Although the AUC ratings listed in thisreport provide general guidance for when transthoracicechocardiography may be useful in a specific patientpopulation, the role of clinical judgment in ordering the


test for an individual patient should not be underminedbecause there may be reasons other than those listed inthis document that preclude application of the AUC. TheAUC may also not be applicable if another diagnosticmodality has already proven the diagnosis for which anechocardiogram was intended. For example, if a vascularring is confirmed by cardiac magnetic resonance imaging(MRI), then an echocardiogram will not provide anyadditional critical information. Even though this indica-tion is rated as Appropriate in this document, clinicaljudgment in such scenarios will definitely supersede theAUC rating.

The definitions provided in this document were final-ized by the writing group after it had given due consid-eration to the current literature and views provided by theexternal reviewers and the rating panel. The users of thisdocument should be well versed in these assumptionsand definitions prior to implementing the AUC.

Indications and Ratings

The indications presented in this report were finalizedafter incorporating the suggestions by the external re-viewers, and the members of the rating panel rated theindications independently. The median score for eachindication became the final rating. In general, the in-dications rated as Appropriate included evaluation ofnew cardiac symptoms or clinical scenarios known to beassociated with congenital or acquired heart disease inthe pediatric population. The indications ranked asRarely Appropriate clustered around broad systemicdiseases and family history of conditions that aregenerally not known to be associated with structural orfunctional abnormalities detectable by echocardiogra-phy. Scenarios that were rated as May Be Appropriate, ingeneral, involved uncertainty or required additionalclinical information to better define the appropriatenessof the test.

In the pediatric population, chest pain, syncope andmurmur are 3 common reasons for referral of an echo-cardiogram in the outpatient setting. For this reason,tables dedicated to each of these conditions with variousclinical scenarios were included in the current report.Although a murmur is one of the most common indica-tions for obtaining an echocardiogram in the pediatricpopulation, it is well known that a large number of pa-tients are referred with an innocent murmur that doesnot require evaluation with an echocardiogram. Thecurrent document presumes that the clinician has madeevery effort to determine whether the murmur is inno-cent or not prior to considering the use of an echocar-diogram (21,31). Echocardiographic screening forpresumably or clearly innocent murmur has been rated asRarely Appropriate in this document. This rating is sup-ported by prior publications reporting that examination



15

151315141515151615171518151915201521152215231524152515261527152815291530153115321533153415351536153715381539154015411542154315441545154615471548154915501551155215531554155515561557155815591560156115621563156415651566

156715681569157015711572157315741575157615771578157915801581158215831584158515861587158815891590159115921593159415951596159715981599160016011602160316041605160616071608160916101611161216131614161516161617161816191620

by a pediatric cardiologist is quite accurate in dis-tinguishing between innocent and pathologic murmurs(21,32,33). Pathologic murmurs (including those that arenot clearly innocent after evaluation), along with pre-sumably innocent murmurs with other signs, symptomsor findings of cardiovascular disease, were found to beAppropriate for an echocardiogram, since these situa-tions suggest the possibility of a cardiovascular abnor-mality as their underlying cause. Of course, the ability tomake a final diagnosis of innocent murmur after anechocardiogram for patients meeting either of theseappropriate indications does not imply that the rationalefor using an echocardiogram to rule out a cardiovascularabnormality was not appropriate.

Chest pain and syncope are 2 other common pre-sentations in the pediatric age group. The etiology forthese is generally benign and echocardiography hasbeen shown to be low-yield, unlike in adult patients(25–29). For this reason, the indications and their ratingsrelated to chest pain in this document are very differentfrom those in the adult AUC. Syncope with no othersymptoms or signs of cardiac disease has been rated asAppropriate in the adult AUC (3), but rated as RarelyAppropriate for pediatric patients (Indication #18),albeit with additional qualifiers of a benign familyhistory and a normal ECG. The reasonableness of usingan echocardiogram as a primary screen versus using anechocardiographic assessment only after a pediatriccardiology consultation for evaluation of a murmur, chestpain, syncope, or any other indication, depends on manyfactors and needs to be given due consideration on acase-by-case basis.

Given the complexity of clinical presentations, it islikely that there will be some overlap between the in-dications in this document. Several indications shareidentical accompanying findings, signs or symptoms, butdiffer as to the primary patient complaint. As such, theratings were driven in these scenarios by the prevalenceof the primary presentation and the likelihood of it beingcardiac-related. For example, non-exertional chest painwith abnormal ECG (A [7] #33) and palpitations withabnormal ECG (M [6] #3) have been rated slightlydifferently by the panel even though they both relate toan abnormal ECG. Given the broad definition of anabnormal ECG described in this paper, it is not unex-pected that the ratings for palpitations that mayaccompany more benign ECG findings were a bit lower.Similarly, ratings for indications related to symptomsor signs of cardiovascular disease changed slightlydepending on other presenting factors described in thescenarios (#29 – chest pain and signs and symptoms – M[6], #40 – presumptively innocent murmur with signsand symptoms – A [7], and #42 – congestive heart failurewith signs and symptoms – A [9]). In applying the AUC, if


more than one indication listed in this document couldbe applied, clinicians need to use their judgment inpicking the scenario that most closely fits the individualpatient.

Comparison With the Adult Cardiology AUC

The current adult cardiology AUC for echocardiographyincludes initial and follow-up evaluation in the inpatientand outpatient setting using transthoracic, trans-esophageal, and stress echocardiography (3). In contrast,this current document is limited to initial outpatienttransthoracic echocardiography. The initial adult car-diology AUC for transthoracic and transesophagealechocardiography were published in 2007 (1). Afterpractical application of these AUC, a revised version waspublished in 2011. This revised version which is currentlyin use included many more indications and now providesa more complete range of clinical scenarios (3). Studiescomparing the application of these two AUC in adultcardiology clinical practice have demonstrated significantimprovement in the ability to classify the various clinicalscenarios using the revised version (34,35). This currentreport for pediatric patients has certainly benefited fromthe maturational process and experience gained by theAUC in adults (36). Implementation studies in thepediatric population will help us to identify any missingor ambiguous indications that could be addressed infuture revisions.

In comparing the ratings of various indications inthe current document with those in the adult AUC, therewere many indications that were rated similarly (3).For example, isolated PACs and sinus bradycardiawere rated as Rarely Appropriate indications in bothdocuments, while SVT, VT, pathologic murmurs, initialevaluation of suspected pulmonary hypertension, sys-temic hypertension, and suspected endocarditis wererated as Appropriate in both. However, there were somestriking differences in the ratings of some indicationssuch as syncope and chest pain due to variations in themost common underlying causes in pediatric versus adultpatients.

There are also differences in format. In this report,prior test results for which a subsequent echocardiogrammay be ordered are listed separately in Table 7 withindividual ratings; but in the adult AUC report they arelumped together under one indication (‘Prior testingthat is concerning for heart disease or structuralabnormality including but not limited to chest X-ray,baseline scout images for stress echocardiogram, ECG, orcardiac biomarkers’ (3)), and are rated as Appropriate.The current report also includes a broad list of systemicdisorders (Table 7) and scenarios related to familyhistory (Table 8) that are not covered in the adult AUCreport.




16

162116221623162416251626162716281629163016311632163316341635163616371638163916401641164216431644164516461647164816491650165116521653165416551656165716581659166016611662166316641665166616671668166916701671167216731674

16751676167716781679168016811682168316841685168616871688168916901691169216931694169516961697169816991700170117021703170417051706170717081709171017111712171317141715171617171718171917201721172217231724172517261727

Limitations

The current AUC report is not fully inclusive of allpossible clinical scenarios and does not include in-dications for follow-up or inpatient echocardiography. Inaddition, it is restricted to the first use of transthoracicechocardiography and does not include indications forfetal or transesophageal echocardiography. Some of theindications have been purposefully kept broad eitherbecause it was beyond the scope of this report to list eachand every possible scenario, or because they wereconsidered fairly uncommon in routine practice. Exam-ples of these broad indications include use of illicit drugs,chest wall deformities, chromosomal abnormalities withundefined risk of cardiovascular disease, suspected con-nective tissue disorders, neurologic or psychiatric disor-ders, gastrointestinal and hepatic disorders and severalindications related to family history.

Though we have attempted to cover a broad range ofclinical scenarios in this document, we realize that by nomeans is this list exhaustive. Given the experience withthe adult cardiology AUC, it would not be surprising for usto have missed some common indications. We alsorecognize that this document does not address theappropriateness, or lack thereof, of not performing echo-cardiograms. This underutilization of echocardiographycould result from a lack of availability (equipment, so-nographer or interpreting cardiologist), denial by payersor lack of insurance, alteration of the management planfollowing expert consultation, or lack of sound clinicaljudgment.

Use of AUC to Improve Care

We foresee several important applications of these AUC inthe pediatric population. The most obvious use of thisdocument will be to support the clinical decision makingof a provider as to the appropriateness of care that theydeliver to an individual pediatric patient. It is importantto keep in mind that an Appropriate rating in this docu-ment should not be misinterpreted as a recommendationto perform an echocardiogram in every patient that meetsthe indications described herein. Rather, it should beinterpreted as something that would be reasonable to doif the information obtained will help in caring for thepatient. On the other hand, a Rarely Appropriate ratingshould not be misinterpreted as one in which an echo-cardiogram should absolutely not be performed. Thiscategory was termed as “Inappropriate” in the initial AUCdocuments, but due to significant misperceptions, theAUC Task Force changed the terminology from Inappro-priate to Rarely Appropriate to emphasize that individualpatient circumstances do exist where an echocardiogramwould be reasonable to perform. Instead of precluding anechocardiogram in an individual patient, the importance


of this category lies more in recognition of a pattern ofordering where a significantly higher number of echo-cardiograms are requested for the Rarely Appropriate in-dications by an individual provider compared with theirpeers. Indications rated as May Be Appropriate could beconsidered reasonable for obtaining an echocardiogram,particularly if the physician taking care of the patientdetermines that it would provide helpful information.These two categories should not be considered as thebasis for denying insurance coverage or reimbursementfor the procedure, as individual decision making isrequired to determine what is best for each patient.Nevertheless, it is important for the clinicians taking careof pediatric patients to recognize that healthcare facil-ities, accreditation bodies, or payers for these tests mayuse this document to ensure quality care and appropriateuse of financial resources.

Ideally, this document will also serve as an educationaland quality improvement tool for addressing the highnumber of Rarely Appropriate referrals for echocardio-grams by individual providers. Experience with the adultechocardiography AUC has shown that physicianengagement in quality improvement programs, andtracking and benchmarking of test ordering behavior, hasreduced the percentage of inappropriate testing (37).Further, lab accreditation organizations such as theIntersocietal Accreditation Commission (IAC) requireattention to AUC as part of their quality improvementprocess (38). Finally, the AUC may provide the basis forevaluation of the impact of using AUC, especially asaccessed by online tools, instead of more onerous andless physician-driven administrative controls on imaginguse.

10. CONCLUSIONS

This AUC report provides a helpful guide to clinicians indetermining the reasonable role of initial transthoracicechocardiography in the evaluation of pediatric patientsin an outpatient setting. It also lays the foundation fordeveloping AUC in other areas of pediatric cardiology.Furthermore, it can form the basis of designing educa-tional and quality improvement projects to improvequality of care. Future studies to evaluate implementa-tion of these AUC in clinical care will be helpful not onlyin identifying any deficiencies in the current document,but also in defining ordering patterns for individualpractitioners and understanding variations in delivery ofcare. We expect that there will be a continued need forrefinement of these AUC based on any gaps identifiedthrough this initial effort, changes in evidence-basedmedicine, and availability of technical and financialresources.


1728

Z. Jen


17

172917301731173217331734173517361737173817391740174117421743174417451746174717481749175017511752175317541755175617571758175917601761176217631764176517661767176817691770177117721773177417751776177717781779178017811782

1783
ACC PRESIDENT AND STAFF
PatricShaloWilliam

ScieJosep

ApLara M

UsAmeli

Po

1784178517861787178817891790

k T. O’Gara, MD, FACC, Presidentm Jacobovitz, Chief Executive Officer

J. Oetgen, MD, FACC, Executive Vice President,nce, Education, and Qualityh M. Allen, MA, Senior Director, Clinical Policy andthways


issa Haidari, MPH, CPHQ, Senior Research Specialist,propriate Use Criteria. Gold, MA, Senior Research Specialist, Appropriate

e Criteriaa Scholtz, PhD, Publications Manager, Clinicallicy and Pathways

1791

Pa

17921793
RE F E RENCE S
179417951796179717981799180018011802180318041805180618071808180918101811181218131814181518161817181818191820182118221823182418251826182718281829183018311832183318341835

1. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriate-ness criteria for transthoracic and transesophagealechocardiography: a report of the American College ofCardiology Foundation Quality Strategic DirectionsCommittee Appropriateness Criteria Working Group,American Society of Echocardiography, American Col-lege of Emergency Physicians, American Society ofNuclear Cardiology, Society for Cardiovascular Angi-ography and Interventions, Society of CardiovascularComputed Tomography, and the Society for Cardio-vascular Magnetic Resonance endorsed by the Amer-ican College of Chest Physicians and the Society ofCritical Care Medicine. J Am Coll Cardiol 2007;50:187–204.

2. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appro-priateness criteria for stress echocardiography: a reportof the American College of Cardiology FoundationAppropriateness Criteria Task Force, American Societyof Echocardiography, American College of EmergencyPhysicians, American Heart Association, American So-ciety of Nuclear Cardiology, Society for CardiovascularAngiography and Interventions, Society of Cardiovas-cular Computed Tomography, and Society for Cardio-vascular Magnetic Resonance endorsed by the HeartRhythm Society and the Society of Critical Care Medi-cine. J Am Coll Cardiol 2008;51:1127–47.

3. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011Appropriate Use Criteria for Echocardiography. AReport of the American College of Cardiology Foun-dation Appropriate Use Criteria Task Force, AmericanSociety of Echocardiography, American Heart Associa-tion, American Society of Nuclear Cardiology, HeartFailure Society of America, Heart Rhythm Society, So-ciety for Cardiovascular Angiography and In-terventions, Society of Critical Care Medicine, Societyof Cardiovascular Computed Tomography, and Societyfor Cardiovascular Magnetic Resonance Endorsed bythe American College of Chest Physicians. J Am CollCardiol 2011;57:1126–66.

4. Lai WW, Geva T, Shirali GS, et al. Guidelines andstandards for performance of a pediatric echocardio-gram: a report from the Task Force of the PediatricCouncil of the American Society of Echocardiography.J Am Soc Echocardiogr 2006;19:1413–30.

5. Lopez L, Colan SD, Frommelt PC, et al. Recom-mendations for quantification methods during theperformance of a pediatric echocardiogram: a reportfrom the Pediatric Measurements Writing Group of theAmerican Society of Echocardiography Pediatric andCongenital Heart Disease Council. J Am Soc Echo-cardiogr 2010;23:465–95.

6. Patel MR, Spertus JA, Brindis RG, et al. ACCF pro-posed method for evaluating the appropriateness ofcardiovascular imaging. J Am Coll Cardiol 2005;46:1606–13.

7. Hendel RC, Patel MR, Allen JM, et al. Appropriateuse of cardiovascular technology: 2013 ACCF appro-priate use criteria methodology update: a report of theAmerican College of Cardiology Foundation appro-priate use criteria task force. J Am Coll Cardiol 2013;61:1305–17.

8. Fitch K, Bernstein S, Aguilar M, et al. The RAND/UCLA Appropriateness Method User’s Manual. Arling-ton, VA: RAND Corporation, 2001.

9. Quinones MA, Otto CM, Stoddard M, et al. Recom-mendations for quantification of Doppler echocardi-ography: a report from the Doppler Quantification TaskForce of the Nomenclature and Standards Committeeof the American Society of Echocardiography. J Am SocEchocardiogr 2002;15:167–84.

10. Thomas JD, Adams DB, Devries S, et al. Guidelinesand recommendations for digital echocardiography.J Am Soc Echocardiogr 2005;18:287–97.

11. Lang RM, Bierig M, Devereux RB, et al. Recom-mendations for chamber quantification: a report fromthe American Society of Echocardiography’s Guidelinesand Standards Committee and the Chamber Quantifi-cation Writing Group, developed in conjunction withthe European Association of Echocardiography, abranch of the European Society of Cardiology. J AmSoc Echocardiogr 2005;18:1440–63.

12. Hancock EW, Deal BJ, Mirvis DM, et al. AHA/ACCF/HRS recommendations for the standardizationand interpretation of the electrocardiogram: part V:electrocardiogram changes associated with cardiacchamber hypertrophy: a scientific statement fromthe American Heart Association Electrocardiographyand Arrhythmias Committee, Council on ClinicalCardiology; the American College of CardiologyFoundation; and the Heart Rhythm Society.Endorsed by the International Society for Computer-ized Electrocardiology. J Am Coll Cardiol 2009;53:992–1002.

13. Rautaharju PM, Surawicz B, Gettes LS, et al. AHA/ACCF/HRS recommendations for the standardizationand interpretation of the electrocardiogram: part IV:the ST segment, T and U waves, and the QT interval: ascientific statement from the American Heart Associa-tion Electrocardiography and Arrhythmias Committee,Council on Clinical Cardiology; the American College ofCardiology Foundation; and the Heart Rhythm Society.Endorsed by the International Society for Computer-ized Electrocardiology. J Am Coll Cardiol 2009;53:982–91.

2 September 20

14. Surawicz B, Childers R, Deal BJ, et al. AHA/ACCF/HRS recommendations for the standardization andinterpretation of the electrocardiogram: part III: intra-ventricular conduction disturbances: a scientificstatement from the American Heart AssociationElectrocardiography and Arrhythmias Committee,Council on Clinical Cardiology; the American Collegeof Cardiology Foundation; and the Heart RhythmSociety. Endorsed by the International Society forComputerized Electrocardiology. J Am Coll Cardiol2009;53:976–81.

15. Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS recommendations for the standardizationand interpretation of the electrocardiogram: part VI:acute ischemia/infarction: a scientific statement fromthe American Heart Association Electrocardiographyand Arrhythmias Committee, Council on Clinical Car-diology; the American College of Cardiology Founda-tion; and the Heart Rhythm Society. Endorsed by theInternational Society for Computerized Electro-cardiology. J Am Coll Cardiol 2009;53:1003–11.

16. Douglas P, Iskandrian AE, Krumholz HM, et al.Achieving quality in cardiovascular imaging: pro-ceedings from the American College of Cardiology-Duke University Medical Center Think Tank on Qualityin Cardiovascular Imaging. J Am Coll Cardiol 2006;48:2141–51.

17. Kemper AR, Mahle WT, Martin GR, et al. Strategiesfor implementing screening for critical congenital heartdisease. Pediatrics 2011;128:e1259–67.

18. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photonemission computed tomography myocardial perfusionimaging (SPECT MPI): a report of the American Collegeof Cardiology Foundation Quality Strategic DirectionsCommittee Appropriateness Criteria Working Groupand the American Society of Nuclear Cardiologyendorsed by the American Heart Association. J Am CollCardiol 2005;46:1587–605.

19. Antman EM, Peterson ED. Tools for guiding clinicalpractice from the american heart association and theamerican college of cardiology: what are they andhow should clinicians use them? Circulation 2009;119:1180–5.

20. Sable CA, Rome JJ, Martin GR, et al. Indications forechocardiography in the diagnosis of infective endo-carditis in children. Am J Cardiol 1995;75:801–4.

21. Danford DA, Nasir A, Gumbiner C. Cost assessmentof the evaluation of heart murmurs in children.Pediatrics 1993;91:365–8.

22. Yi MS, Kimball TR, Tsevat J, et al. Evaluation ofheart murmurs in children: cost-effectiveness andpractical implications. J Pediatr 2002;141:504–11.

14 � 3:25 pm � ce

1836



18

183718381839184018411842184318441845184618471848184918501851185218531854185518561857185818591860186118621863186418651866186718681869187018711872187318741875187618771878187918801881188218831884188518861887188818891890

1891189218931894189518961897189818991900190119021903190419051906

23. Friedman KG, Kane DA, Rathod RH, et al.Management of pediatric chest pain using a standard-ized assessment and management plan. Pediatrics2011;128:239–45.

24. McCrindle BW, Shaffer KM, Kan JS, et al. Cardinalclinical signs in the differentiation of heart murmurs inchildren. Arch Pediatr Adolesc Med 1996;150:169–74.

25. Drossner DM, Hirsh DA, Sturm JJ, et al. Cardiacdisease in pediatric patients presenting to a pediatricED with chest pain. Am J Emerg Med 2011;29:632–8.

26. Massin MM, Bourguignont A, Coremans C, et al.Chest pain in pediatric patients presenting to anemergency department or to a cardiac clinic. ClinPediatr (Phila) 2004;43:231–8.

27. Ritter S, Tani LY, Etheridge SP, et al. What is theyield of screening echocardiography in pediatric syn-cope? Pediatrics 2000;105:E58.

28. Steinberg LA, Knilans TK. Syncope in children:diagnostic tests have a high cost and low yield.J Pediatr 2005;146:355–8.

PGL 5.2.0 DTD �

29. Verghese GR, Friedman KG, Rathod RH, et al.Resource Utilization Reduction for Evaluation of ChestPain in Pediatrics Using a Novel Standardized ClinicalAssessment and Management Plan (SCAMP). Journalof the American Heart Assocation 2012;1.

30. Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/AHA Guidelines for the Clinical Application of Echo-cardiography. A report of the American College ofCardiology/American Heart Association Task Force onPractice Guidelines (Committee on Clinical Applicationof Echocardiography). Developed in collaboration withthe American Society of Echocardiography. Circulation1997;95:1686–744.

31. Rosenthal A. How to distinguish between innocentand pathologic murmurs in childhood. Pediatr ClinNorth Am 1984;31:1229–40.

32. Newburger JW, Rosenthal A, Williams RG, et al.Noninvasive tests in the initial evaluation ofheart murmurs in children. N Engl J Med 1983;308:61–4.

JAC20491_proof � 12 September 2014 � 3:2

33. Geva T, Hegesh J, Frand M. Reappraisal of theapproach to the child with heart murmurs: is echo-cardiography mandatory? Int J Cardiol 1988;19:107–13.

34. Bhatia RS, Carne DM, Picard MH, et al. Comparisonof the 2007 and 2011 appropriate use criteria fortransthoracic echocardiography in various clinical set-tings. J Am Soc Echocardiogr 2012;25:1162–9.

35. Mansour IN, Razi RR, Bhave NM, et al. Comparisonof the updated 2011 appropriate use criteria for echo-cardiography to the original criteria for transthoracic,transesophageal, and stress echocardiography. J AmSoc Echocardiogr 2012;25:1153–61.

36. Douglas PS. Appropriate use criteria: past, present,future. J Am Soc Echocardiogr 2012;25:1176–8.

37. Imaging in “FOCUS”. Available at: http://www.cardiosource.org/focus. Accessed January 24, 2014.

38. Echocardiography/ ICAEL: Accreditation Evolved.Available at: http://www.intersocietal.org/echo/.Accessed January 24, 2014.

1907
1908 190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944
APPENDIX A. APPROPRIATE USE CRITERIA FOR

INITIAL TRANSTHORACIC ECHOCARDIOGRAPHY

IN OUTPATIENT PEDIATRIC CARDIOLOGY:

PARTICIPANTS

Writing Group

Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS—Chief, Children’s Healthcare of Atlanta Sibley HeartCenter, Professor and Division Director of Cardiology,Department of Pediatrics, Emory University School ofMedicine, Atlanta, GA

Pamela S. Douglas, MD, MACC, FAHA, FASE—PastPresident, American College of Cardiology; Past Presi-dent, American Society of Echocardiography, and UrsulaGeller Professor of Research in Cardiovascular Diseases,Duke University Medical Center, Durham, NC

Benjamin W. Eidem, MD, FACC, FASE—Past President,Society of Pediatric Echocardiography; Past Chair,Pediatric & Congenital Heart Disease Council; Past mem-ber, Board of Directors, American Society of Echocardiog-raphy; and Professor of Medicine and Pediatrics, Divisionof Pediatric Cardiology, Department of Pediatric andAdolescent Medicine, Mayo Graduate School of Medicine,Mayo Clinic College of Medicine, Rochester, MN

Wyman W. Lai, MD, MPH, FACC, FASE—Chair, Pediatricand Congenital Council Board, American Society ofEchocardiography; Director of Non-invasive CardiacImaging, Pediatric Echocardiography Laboratory, andCongenital Cardiac MRI Program, Division of PediatricCardiology, Department of Pediatrics, New York Presby-terian Morgan Stanley Children’s Hospital, New York, NY

Leo Lopez, MD, FACC, FAAP, FASE—Chair, Pedia-tric and Congenital Heart Disease Council, AmericanSociety of Echocardiography; Director, Pediatric CardiacNon-invasive Imaging at the Children’s Hospital at

Montefiore; and Associate Professor of Clinical Pediatrics,Albert Einstein College of Medicine, New York, NY

Ritu Sachdeva, MD, FACC, FAAP, FASE—AssociateProfessor, Emory University; and Director, CardiovascularImaging Research Core, Children’s Healthcare of Atlanta,Sibley Heart Center, Atlanta, GA

Rating Panel

Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS,Writing Committee Liaison—Chief, Children’s Healthcareof Atlanta Sibley Heart Center; Professor and DivisionDirector of Cardiology, Department of Pediatrics, EmoryUniversity School of Medicine, Atlanta, GA

Pamela S. Douglas, MD, MACC, FAHA, FASE, Moder-ator—Past President, American College of Cardiology;Past President, American Society of Echocardiography;and Ursula Geller Professor of Research in Cardio-vascular Diseases, Duke University Medical Center,Durham, NC

Louis I. Bezold, MD, FACC, FAAP, FASE—UK HealthCare Enterprise Quality Director, Jennifer Gill RobertsProfessor in Pediatric Cardiology, and Vice Chair of Pedi-atrics, University of Kentucky, Lexington, KY

William B. Blanchard, MD, FACC, FAAP, FAHA—PastMedical Director of Nemours Children’s Clinic in Pensa-cola, FL; Past President, American Heart AssociationFlorida/Puerto Rico Affiliate; Statewide Associate Pediat-ric Cardiology Consultant for Children’s Medical Services,FL; and Medical Director, Florida Association of Chil-dren’s Hospitals, FL

Jeffrey R. Boris, MD, FACC, FAAP—Clinical AssociateProfessor of Pediatrics; Director, Postural OrthostaticTachycardia Syndrome Program; and Pediatric Cardiolo-gist, Division of Cardiology, Children’s Hospital of Phila-delphia, Philadelphia, PA

5 pm � ce

http://www.cardiosource.org/focus

http://www.cardiosource.org/focus

http://www.intersocietal.org/echo/


19

194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998

199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046204720482049205020512052

Bryan Cannon, MD—Associate Professor of Pediatrics,and Director, Pediatric Arrhythmia and Pacing Service,Mayo Clinic, Rochester, MN

Gregory J. Ensing, MD, FACC, FASE—Member of theASE Pediatric Council Board, and Professor of Pediatricsand Pediatric Cardiology, University of Michigan CS MottHospital for Children, Ann Arbor, MI

Craig E. Fleishman, MD, FACC, FASE—President, Soci-ety of Pediatric Echocardiography; Medical Director, Non-Invasive Cardiac Imaging, The Heart Center at ArnoldPalmer Hospital for Children; and Associate Professor ofPediatrics, University of Central Florida College of Medi-cine, Orlando, FL

Mark A. Fogel, MD, FACC, FAHA, FAAP—Professor ofCardiology and Radiology, University of PennsylvaniaSchool of Medicine; Past member, Board of Trustees,Society for Cardiovascular Magnetic Resonance; Pastmember, American College of Cardiology Imaging Coun-cil; Member, Board of Scientific Counselors, NationalHeart Lung and Blood Institute of the National Institute ofHealth; and Director of Cardiac Magnetic Resonance, TheChildren’s Hospital of Philadelphia, Division of Cardiol-ogy, Philadelphia, PA

B. Kelly Han, MD, FACC—Director of Congenital CardiacImaging, Minneapolis Heart Institute and the Children’sHeart Clinic at the Children’s Hospitals and Clinics ofMinnesota, Minneapolis, MN

Shabnam Jain, MD, MPH, FAAP—Associate Professor ofPediatrics and Emergency Medicine; Director for Quality,Pediatric Emergency Medicine, Emory University; Medi-cal Director for Clinical Effectiveness, Children’s Health-care of Atlanta, Atlanta, GA

Mark B. Lewin, MD—Professor and Chief, Division ofPediatric Cardiology, University of Washington School ofMedicine; and Co-Director, Heart Center, Seattle Chil-dren’s Hospital, Seattle, WA

Richard H. Lockwood, MD—Associate Medical Director,Excellus Blue Cross Blue Shield, Syracuse, NY

G. Paul Matherne, MD, MBA, FACC, FAHA—DammannProfessor of Pediatrics, Vice Chair for Clinical Affairs, andAssociate Chief Medical Officer, University of VirginiaChildren’s Hospital, Charlottesville, VA

David Nykanen, MD, FACC, FRCPC, FSCAI—Member,Executive Committee, Congenital Heart Disease Council,Society for Cardiovascular Angiography and Inter-ventions; Co-Director, The Heart Center; and Chief, Car-diology and Cardiac Catheterization, Arnold PalmerHospital for Children, Orlando, FL

Catherine L. Webb, MD, FACC, FAHA, FASE—Past Chair,Council on Cardiovascular Disease in the Young, Amer-ican Heart Association; Past Co-Chair, Congenital HeartPublic Health Consortium; Past Board Member, Sub-boardof Pediatric Cardiology, American Board of Pediatrics; andProfessor of Pediatrics and Communicable Diseases,


Michigan Congenital Heart Center, University of MichiganMedical School, Ann Arbor, MI

Robert Wiskind, MD, FAAP—President, Georgia Chapterof the American Academy of Pediatrics; Managing Part-ner, Peachtree Park Pediatrics, Atlanta, GA

Reviewers

Meryl S. Cohen, MD—Medical Director, Non-InvasiveCardiovascular Laboratory, The Children’s Hospital ofPhiladelphia, Philadelphia, PA

Mario J. Garcia, MD, FACC—Chief, Division of Cardiol-ogy, Professor of Medicine and Radiology, and Co-Director,Montefiore-Einstein Center for Heart and Vascular Care,Montefiore Medical Center, The University Hospital forthe Albert Einstein College of Medicine, Bronx, NY

Michael Gewitz, MD, FACC, FAAP, FAHA—Professorand Physician-in-Chief, Pediatric Cardiology, Maria FareriChildren’s Hospital at Westchester Medical Center; andProfessor and Vice Chairman, Department of Pediatrics,New York Medical College, Valhalla, NY

Willem A. Helbing, MD—Professor of Pediatric Cardiol-ogy, Erasmus University Medical Center, Sophia Chil-dren’s Hospital, Rotterdam, The Netherlands

Alexander J. Javois, MD, FACC, FAAP, FSCAI—AssistantClinical Professor of Pediatrics, University of IllinoisMedical Center, Advocate Children’s Hospital, Oak Lawn,IL

Walter H. Johnson, Jr, MD—Professor of Pediatrics, Di-vision of Pediatric Cardiology, Alabama Congenital HeartDisease Center, University of Alabama at Birmingham &Children’s of Alabama, Birmingham, AL

Ann Kavanaugh-McHugh, MD—Associate Professor ofPediatrics, and Director of Pediatric Cardiology ImagingLaboratory, Division of Pediatric Cardiology, VanderbiltUniversity Medical Center

H. Helen Ko, BS, RDMS, RDCS, FASE—TechnicalDirector/Operations Manager, Pediatric Echocardiogra-phy, Mount Sinai Medical Center, New York, NY

Seema Mital, MD, FACC, FAHA, FRCPC—Professor ofPediatrics, Hospital for Sick Children, University of Tor-onto, Toronto, Ontario, Canada

Andrew J. Powell, MD—Associate Professor of Pediat-rics, Harvard Medical School; Senior Associate in Cardi-ology, Department of Cardiology, Boston Children’sHospital, Boston, MA

J. Carter Ralphe, MD—Assistant Professor of Pediatrics,and Chief, Pediatric Cardiology, University of WisconsinSchool of Medicine & Public Health, Madison, WI

Arno AW Roest, MD, PhD—Pediatric Cardiologist, Divisionof Pediatric Cardiology, Department of Pediatrics, LeidenUniversity Medical Center, Leiden, The Netherlands

Jennifer N. A. Silva, MD—Pediatric Electrophysiology,Washington University School of Medicine, St. LouisChildren’s Hospital, St. Louis, MO




20

205320542055205620572058205920602061206220632064206520662067206820692070207120722073207420752076207720782079208020812082208320842085208620872088208920902091209220932094209520962097209820992100210121022103210421052106

2107210821092110211121122113211421152116211721182119212021212122212321242125212621272128212921302131213221332134213521362137213821392140214121422143214421452146

Julia Steinberger, MD, MS—Professor of Pediatrics, andDwan Chair of Pediatric Cardiology, University of Min-nesota Amplatz Children’s Hospital, Minneapolis, MN

ACC Appropriate Use Criteria Task Force

Steven R. Bailey, MD, FACC, FSCAI, FAHA—Chair, Divi-sion of Cardiology, Professor of Medicine and Radiology,Janey Briscoe Distinguished Chair, University of TexasHealth Sciences Center, San Antonio, TX

Alan S. Brown, MD, FACC—Medical Director, MidwestHeart Disease Prevention Center, Midwest Heart Special-ists, Edward Heart Hospital, Naperville, IL

John U. Doherty, MD, FACC, FAHA—Professor of Med-icine, Jefferson Medical College of Thomas JeffersonUniversity, Philadelphia, PA

Pamela S. Douglas, MD, MACC, FAHA, FASE—PastPresident, American College of Cardiology; Past Presi-dent, American Society of Echocardiography; and UrsulaGeller Professor of Research in Cardiovascular Diseases,Duke University Medical Center, Durham, NC

Robert C. Hendel, MD, FACC, FAHA, FASNC—Chair,Appropriate Use Criteria for Radionuclide ImagingWriting Group; Director of Cardiac Imaging and Outpa-tient Services, Division of Cardiology, Miami UniversitySchool of Medicine, Miami, FL

Christopher M. Kramer, MD, FACC, FAHA—Co-Chair,AUC Task Force, Ruth C. Heede Professor of Cardiology andRadiology, and Director, Cardiovascular Imaging Center,University of Virginia Health System, Charlottesville, VA

Bruce D. Lindsay, MD, FACC—Professor of Cardiology,Cleveland Clinic Foundation of Cardiovascular Medicine,Cleveland, OH

Manesh R. Patel, MD, FACC— Chair, AUC Task Force,Assistant Professor of Medicine, Division of Cardiology,Duke University Medical Center, Durham, NC

Leslee Shaw, PhD, FACC, FASNC— Professor of Medi-cine, Emory University School of Medicine, Atlanta, GA

Raymond F. Stainback, MD, FACC, FASE—Medical Di-rector of Non-invasive Cardiac Imaging, Texas HeartInstitute at St. Luke’s Episcopal Hospital; Clinical


Associate Professor of Medicine, Baylor College of Medi-cine, Houston, TX

L. Samuel Wann, MD – Columbia St. Mary’s Healthcare,Milwaukee, WI

Joseph M. Allen, MA—Senior Director, American Col-lege of Cardiology, Washington, DC

APPENDIX B. RELATIONSHIPS WITH INDUSTRY

(RWI) AND OTHER ENTITIES

The College and its partnering organizations rigorouslyavoid any actual, perceived, or potential conflicts of in-terest that might arise as a result of an outside relation-ship or personal interest of a member of the rating panel.Specifically, all panelists are asked to provide disclosurestatements of all relationships that might be perceivedas real or potential conflicts of interest. These statementswere reviewed by the Appropriate Use Criteria TaskForce, discussed with all members of the rating panel atthe face-to-face meeting, and updated and reviewed asnecessary. A table of relevant disclosures by the ratingpanel and oversight working group members can be foundbelow. In addition, to ensure complete transparency,a full list of disclosure information—including relation-ships not pertinent to this document—is available in theOnline Appendix.

Appropriate Use Criteria for Initial TransthoracicEchocardiography in Outpatient Pediatric Cardiology: Membersof the Writing Group, Rating Panel, Indication Reviewers, andAUC Task Force—Relationships with Industry and Other Entities(Relevant)

Note: A standard exemption to the ACC RWI policy isextended to Appropriate Use Criteria writing groups,since they do not make recommendations but ratherprepare background materials and typical clinical sce-narios/indications that are rated independently by aseparate panel of experts.


21472148214921502151215221532154215521562157215821592160

http://jaccjacc.cardiosource.com/acc_documents/Peds_Echo_Online_Appx_Comprehensive_RWI_tables.pdf

Participant ConsultantSpeakersBureau

Ownership/Partnership/Principal Personal Research

Institutional,Organizational,

or Other FinancialBenefit

ExpertWitness

Writing Group

Robert M. Campbell None None None None None None

Pamela S. Douglas None None None None None None

Benjamin W. Eidem None None None None None None

Wyman W. Lai None None None None None None

Leo Lopez None None None None None None

Ritu Sachdeva None None None None None None

Rating Panel

Louis I. Bezold None None None None None None

William B. Blanchard None None None None None None

Jeffrey R. Boris None None None None None None

Bryan Cannon None None None None None None

Gregory J. Ensing None None None None None None

Craig E. Fleishman � Gore MedicalSupplies

None None None None None

Mark A. Fogel None None None � Siemens MedicalSystems

None None

B. Kelly Han None None None � Siemens MedicalSystems

None None

Shabnam Jain None None None None None None

Mark B. Lewin None None None None None None

Richard H. Lockwood None None None None � Excellus BCBS* None

G. Paul Matherne None None None None None None

David Nykanen None None None None None None

Catherine L. Webb None None None None None None

Robert Wiskind None None None None None None

Reviewers

Meryl S. Cohen None None None None None None

Mario J. Garcia None None None None None None

Michael Gewitz None None None None None None

Willem A. Helbing None None None None None None

Alexander J. Javois None None None None None None

Walter H. Johnson None None None None None None

Ann Kavanaugh-McHugh None None None None None None

Hyun-Sook Helen Ko None None None None None None

Seema Mital None None None None None None

Andrew J. Powell None None None None None None

J. Carter Ralphe None None None None None None

Arno AW Roest None None None None None None

Jennifer Silva None None None None None None

Julia Steinberger None None None None None None

(continued on the next page)

APPENDIX B. CONTINUED


21

216121622163216421652166216721682169217021712172217321742175217621772178217921802181218221832184218521862187218821892190219121922193219421952196219721982199220022012202220322042205220622072208220922102211221222132214

221522162217221822192220222122222223222422252226222722282229223022312232223322342235223622372238223922402241224222432244224522462247224822492250225122522253225422552256225722582259226022612262226322642265


226622672268

Participant ConsultantSpeakersBureau

Ownership/Partnership/Principal Personal Research

Institutional,Organizational,

or Other FinancialBenefit

ExpertWitness

Appropriate Use Criteria Task Force

Steven R. Bailey None None None None None None

Alan S. Brown None None None None None None

John U. Doherty None None None None None None

Pamela S. Douglas None None None None None None

Robert C. Hendel None None None None None None

Christopher M. Kramer None None None � Siemens MedicalSolutions

None None

Bruce D. Lindsay None None None None None None

Manesh R. Patel None None None None None None

Leslee J. Shaw None None None None None None

Raymond Stainback None None None None None None

L. Samuel Wann None None None None None None

Joseph M. Allen None None None None None None

This table represents the relevant relationships with industry and other entities that were disclosed by participants at the time of participation. It does not necessarily reflect re-lationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stockor share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5%of the person’s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table aremodest unless otherwise noted. Names are listed in alphabetical order within each category of review. Participation does not imply endorsement of this document.*Significant (greater than $10,000) relationship.

APPENDIX B. CONTINUED



22


226922702271227222732274227522762277227822792280228122822283228422852286228722882289229022912292229322942295229622972298229923002301230223032304230523062307230823092310231123122313231423152316231723182319232023212322

232323242325232623272328232923302331233223332334233523362337233823392340234123422343234423452346234723482349235023512352235323542355235623572358235923602361236223632364236523662367236823692370237123722373237423752376

Documents

ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE …asecho.org/wordpress/wp-content/uploads/2014/09/Pediatric-AUC... · Task Force, American Academy of Pediatrics, American Heart Association,